创伤出血性休克后急性呼吸窘迫综合征的危险因素

doi:10.19723/j.issn.1671-167X.2024.02.016

摘要/Abstract

摘要：

目的: 探讨创伤出血性休克后急性呼吸窘迫综合征(acute respiratory distress syndrome，ARDS)的危险因素。方法: 回顾性研究2012年12月至2021年8月期间共314名创伤出血性休克患者，其中男性患者152名，女性患者162名，年龄中位数为63.00 (49.75~82.00)岁。记录患者住院期间的各项临床指标，根据入院7 d内是否发生ARDS将患者分为两组，即ARDS组(n=89)和非ARDS组(n=225)，通过判定差异寻找ARDS的危险因素，并建立预测是否出现ARDS的回归模型。结果: 创伤出血性休克后ARDS的发生率为28.34%，Logistic回归模型分析发现创伤出血性休克后ARDS的独立危险因素包括男性、冠状动脉粥样硬化性心脏病(简称冠心病)史、高急性生理与慢性健康评分Ⅱ(acute physiology and chronic health evaluation Ⅱ，APACHE Ⅱ)、受伤原因为车祸伤和肌钙蛋白Ⅰ升高，各独立危险因素的OR值及95%可信区间(confidence intervals，CI)分别为4.01(95%CI：1.75~9.20)、5.22(95%CI：1.29~21.08)、1.07(95%CI：1.02~1.57)、2.53(95%CI：1.21~5.28)和1.26(95%CI：1.02~1.57)，P值分别为0.001、0.020、0.009、0.014和0.034。预测创伤出血性休克后ARDS的受试者工作特征(receiver operating characteristic，ROC)曲线下面积(area under curve，AUC)分别为：男性0.59 (95%CI：0.51~0.68)、冠心病史0.55(95%CI：0.46~0.64)、APACHE Ⅱ评分0.65(95%CI：0.57~0.73)、受伤原因为车祸伤0.58(95%CI：0.50~0.67)、肌钙蛋白Ⅰ 0.73(95%CI：0.66~0.80)，总体预测值为0.81(95%CI：0.74~0.88)。结论: ARDS在创伤出血性休克患者中发生率较高，男性、冠心病史、高APACHE Ⅱ评分、受伤原因为车祸伤和肌钙蛋白Ⅰ升高是创伤出血性休克后ARDS的独立危险因素，及时监测这几项指标有利于早期识别和治疗创伤出血性休克后ARDS。

关键词: 急性呼吸窘迫综合征, 创伤, 出血性休克, 危险因素

Abstract:

Objective: To investigate the risk factors of acute respiratory distress syndrome (ARDS) after traumatic hemorrhagic shock. Methods: This was a retrospective cohort study of 314 patients with traumatic hemorrhagic shock at Trauma Medicine Center, Peking University People's Hospital from December 2012 to August 2021, including 152 male patients and 162 female patients, with a median age of 63.00 (49.75-82.00) years. The demographic data, past medical history, injury assessment, vital signs, laboratory examination and other indicators of these patients during hospitalization were recorded. These patients were divided into two groups, ARDS group (n=89) and non-ARDS group (n=225) according to whether there was ARDS within 7 d of admission. Risk factors for ARDS were identified using Logistic regression. The C-statistic expressed as a percentage [area under curve (AUC) of the receiver operating characteristic (ROC) curve] was used to assess the discrimination of the model. Results: The incidence of ARDS after traumatic hemorrhagic shock was 28.34%. Finally, Logistic regression model showed that the independent risk factors of ARDS after traumatic hemorrhagic shock included male, history of coronary heart disease, high acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score, road traffic accident and elevated troponin Ⅰ. The OR and 95% confidence intervals (CI) were 4.01 (95%CI: 1.75-9.20), 5.22 (95%CI: 1.29-21.08), 1.07 (95%CI: 1.02-1.57), 2.53 (95%CI: 1.21-5.28), and 1.26 (95%CI: 1.02-1.57), respectively; the P values were 0.001, 0.020, 0.009, 0.014, and 0.034, respectively. The ROC curve was used to analyze the value of each risk factor in predicting ARDS. It was found that the AUC for predicting ARDS after traumatic hemorrhagic shock was 0.59 (95%CI: 0.51-0.68) for male, 0.55 (95%CI: 0.46-0.64) for history of coronary heart disease, 0.65 (95%CI: 0.57-0.73) for APACHE Ⅱ score, 0.58 (95%CI: 0.50-0.67) for road traffic accident, and 0.73 (95%CI: 0.66-0.80) for elevated troponin Ⅰ, with an overall predictive value of 0.81 (95%CI: 0.74-0.88). Conclusion: The incidence of ARDS in patients with traumatic hemorrhagic shock is high, and male, history of coronary heart disease, high APACHE Ⅱ score, road traffic accident and elevated troponin Ⅰ are independent risk factors for ARDS after traumatic hemorrhagic shock. Timely monitoring these indicators is conducive to early detection and treatment of ARDS after traumatic hemorrhagic shock.

Key words: Acute respiratory distress syndrome, Trauma, Hemorrhagic shock, Risk factors

中图分类号:

R563.8

司筱芊,赵秀娟,朱凤雪,王天兵. 创伤出血性休克后急性呼吸窘迫综合征的危险因素[J]. 北京大学学报（医学版）, 2024, 56(2): 307-312.

Xiaoqian SI,Xiujuan ZHAO,Fengxue ZHU,Tianbing WANG. Risk factors for acute respiratory distress syndrome in patients with traumatic hemorrhagic shock[J]. Journal of Peking University (Health Sciences), 2024, 56(2): 307-312.

图/表 3

表1

创伤出血性休克ARDS组与非ARDS组间各项危险因素的比较"

Characters	ARDS group (n=89)	Non-ARDS group (n=225)	Statistics	P value
Gender			15.907	<0.001
Male	59 (66.29)	93 (41.33)
Female	30 (33.71)	132 (58.67)
Age/years	63.00 (51.00, 82.00)	63.00 (49.00, 82.00)	0.106	0.916
Preadmission conditions
Chronic renal insufficiency	2 (2.25)	2 (0.89)	0.936	0.333
Coronary heart disease	10 (11.24)	8 (3.56)	6.962	0.008
Hypertension	28 (31.46)	74 (32.89)	0.059	0.808
Diabetes mellitus	9 (10.11)	36 (16.00)	1.801	0.180
Causes of trauma
Road traffic accident	35 (39.33)	60 (26.67)	4.779	0.024
Falling from height	15 (16.85)	32 (14.22)	0.347	0.556
Falling from a standing position	34 (38.20)	112 (49.78)	3.435	0.064
Others (crush, stab, animal bite)	5 (5.62)	21 (9.33)	1.159	0.282
Main bleeding site
Thoracic	24 (26.97)	31 (13.78)	7.678	0.006
Abdominal	13 (14.61)	21 (9.33)	1.837	0.175
Pelvic	10 (11.23)	21 (9.33)	0.259	0.610
Limbs	35 (39.33)	109 (48.44)	2.347	0.126
Others (blood vessels, skin, soft tissue)	7 (7.86)	43 (19.11)	6.024	0.014
Mean arterial pressure/mmHg	61.20 (50.82, 71.58)	67.30 (58.01, 76.59)	1.894	0.058
Heart rate/(beats/min)	124.00 (108.00, 140.00)	109.50 (94.00, 125.00)	3.926	<0.001
Shock index	1.16 (0.90, 1.67)	1.03 (0.76, 1.26)	3.318	0.001
Perfusion index	3.7 (0.7, 4.3)	4.0 (1.2, 4.4)	1.788	0.074
Central venous pressure/mmHg	4.00 (2.25, 6.75)	5.00 (3.00, 7.00)	2.151	0.032
Respiration rate/(breaths/min)	25.00 (21.50, 30.50)	22.00 (19.00, 25.00)	2.715	0.007
Temperature/℃	37.70 (37.00, 38.30)	37.50 (37.00, 38.00)	1.472	0.141
Laboratory test
Leukocyte count/(×10⁹/L)	9.96 (5.71, 14.21)	10.73 (8.23, 13.23)	3.206	0.001
Lymphocyte count/(×10⁹/L)	0.79 (0.54, 1.04)	0.76 (0.44, 1.08)	0.559	0.576
Hemoglobin/(g/L)	92.00 (76.38, 107.63)	96.00 (80.38, 111.63)	0.484	0.629
Platelet count/(×10⁹/L)	131.50 (87.50, 175.50)	132.00 (91.00, 173.00)	0.302	0.762
Serum albumin/(g/L)	29.65 (23.20, 33.43)	31.50 (27.05, 36.00)	2.937	0.003
Serum creatinine/(μmol/L)	76.00 (61.00, 117.00)	69.00 (54.50, 89.50)	2.492	0.013
Total bilirubin/(μmol/L)	15.05 (9.95, 20.20)	14.30 (10.85, 21.00)	0.472	0.637
Fibrinogen/(mg/dL)	175.00 (92.00, 258.00)	180.50 (106.50, 254.50)	1.874	0.061
Cardiac troponin Ⅰ/(μg/L)	0.194 (0.032, 0.697)	0.020 (0.006, 0.094)	6.237	<0.001
Lactate/(mmol/L)	3.10 (1.95, 3.90)	3.00 (1.60, 6.18)	0.803	0.422
C-reactive protein/(mg/L)	41.8 (13.45, 87.65)	28.7 (11.0, 67.03)	1.230	0.219
Interleukin-6/(ng/L)	112.95 (48.45, 189.35)	87.50 (36.80, 156.40)	1.362	0.172
ISS	27.16 (19.66, 34.66)	22.00 (14.50, 29.50)	3.681	<0.001
APACHE Ⅱ score	19.00 (17.00, 23.00)	16.00 (12.00, 20.00)	4.779	<0.001
Hospital mortality	15 (16.85)	15 (6.67)	7.659	0.006

表1

表2

图1

参考文献 16

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Characters	Univariate analysis		Multivariate analysis
Characters	P	OR (95%CI)	β	Wald	P	OR (95%CI)
Male	<0.001	2.791 (1.671-4.664)	1.389	10.740	0.001	4.009 (1.747-9.199)
History of coronary heart disease	0.012	3.434 (1.309-9.010)	1.653	5.389	0.020	5.222 (1.293-21.080)
Road traffic accident	0.029	1.782 (1.062-2.992)	0.926	6.048	0.014	2.532 (1.207-5.277)
Thoracic bleeding	0.006	2.311 (1.265-4.220)
Bleeding at other sites	0.018	0.361 (0.156-0.837)
Heart rate	0.017	1.047 (1.008-1.088)
Shock index	<0.001	2.446 (1.491-4.014)
Central venous pressure	0.025	0.882 (0.790-0.984)
Respiration rate	0.291	1.158 (0.882-1.519)
Leukocyte count	0.009	1.059 (1.014-1.106)
Serum albumin	0.003	0.943 (0.907-0.980)
Serum creatinine	0.052	1.005 (1.000-1.009)
Cardiac troponin Ⅰ	0.002	1.420 (1.133-1.779)	0.234	4.489	0.034	1.264 (1.018-1.569)
ISS	<0.001	1.045 (1.019-1.071)
APACHE Ⅱ score	<0.001	1.094 (1.048-1.141)	0.071	6.852	0.009	1.074 (1.018-1.569)